Stephen Morley

Is exocrine pancreatic insufficiency in adult coeliac disease a cause of persisting symptoms

Patients with coeliac disease may have diarrhoea despite being on a gluten‐free diet.

Faecal lactoferrin – a novel test to differentiate between the irritable and inflamed bowel?

Aliment Pharmacol Ther 31, 1365–1370

Undisclosed Use of Nonsteroidal Anti-Inflammatory Drugs May Underlie Small-Bowel Injury Observed by Capsule Endoscopy

BACKGROUND & AIMS Findings from capsule endoscopies (CEs) of patients with enteropathy from nonsteroidal anti-inflammatory drugs (NSAIDs) may be indistinguishable from those with Crohns disease, making medication history crucial to image interpretation. Undeclared NSAID use has been proposed to cause unexplained peptic ulcers; we investigated whether it is also an issue among patients referred for small-bowel CE. METHODS We collected demographic data, indications for CE, and medication history prospectively. A salicylate spot test and gas chromatography-mass spectrometry were performed for NSAID metabolites in urine samples of patients undergoing routine CE. Videos were analyzed by a gastroenterologist who was blinded to the urinalysis results. RESULTS Seventy-six patients (52 women; mean age, 50 y) underwent CE for suspected small-bowel pathology. Urinalysis was positive in 13.6% of patients (salicylates, n = 3; ibuprofen, n = 6; and ibuprofen and diclofenac, n = 1) although only 1 of these patients declared use of an NSAID (aspirin). Although 2 patients had normal CE results, 80% had positive results, including the presence of erosions (n = 5), ulceration (n = 2), and ulcers with early stricturing (n = 1, diagnosed with Crohns disease). A patient with small-bowel ulceration underwent surgery and was found to have NSAID-associated enteropathy, based on histologic analysis. CONCLUSIONS Of patients who undergo CE, 13.6% took NSAIDs or aspirin, but most did not declare using these medications. Small-bowel inflammation was common in this cohort and could be mistaken for Crohns disease. Patients should be questioned about use of over-the-counter medications, and routine urinalysis for NSAID metabolites may be helpful before interpretation of CE findings.

Albumin level and patient age predict outcomes in patients referred for gastrostomy insertion: internal and external validation of a gastrostomy score and comparison with artificial neural networks

BACKGROUND Significant mortality after gastrostomy insertion remains and some risk factors have been identified, but no predictive scoring system exists. OBJECTIVE To identify risk factors for mortality, formulate a predictive scoring system, and validate the score. Comparison to an artificial neural network (ANN). DESIGN Endoscopic database analysis. SETTING Six hospitals (2 teaching hospitals) in the South Yorkshire region, United Kingdom. PATIENTS This study involved all patients referred for gastrostomy insertion. INTERVENTION Generation of clinical scores to predict 30-day mortality in patients undergoing gastrostomy insertion. MAIN OUTCOME MEASUREMENTS Risk factors for 30-day mortality. Internal and external validation of the score. Comparison with an ANN. RESULTS Univariate analysis showed that 30-day mortality was associated with age, albumin levels, and cardiac and neurological comorbidities. Multivariate analysis showed that only age and albumin levels were independent. Modeling provided scores of 0, 1, 2, and 3 corresponding to 30-day mortalities of 0% (0-2.1), 7% (2.9-13.9), 21.3% (13.5-30.9), and 37.3% (24.1-51.9), respectively. Application of the scoring system at the other teaching hospital and the 4 district general hospitals gave 30-day mortality rates that were not significantly different from those predicted. Receiver operating characteristic curves for the score and the ANN were comparable. LIMITATIONS Nonrandomized study. Score not used as a decision-making tool. CONCLUSION The gastrostomy score provides an estimate of 30-day mortality for patients (and their relatives) when gastrostomy insertion is being discussed. This score requires evaluation as a decision-making tool in clinical practice. ANN analysis results were similar to the outcomes from the clinical score.

Can faecal lactoferrin be used as a discriminator for referral for colonoscopy

high-sensitivity troponin testing on clinical practice. Intern Medicine J 2010; 40: 171–2. 3 Reichlin T, Hochholzer W, Bassetti S, Steuer S, Stelzig C, Hartwiger S et al. Early diagnosis of myocardial infarction with sensitive cardiac troponin assays. N Engl J Med 2009; 361: 858–67. 4 Keller T, Zeller T, Peetz D, Tzikas S, Roth A, Czyz E et al. Sensitive troponin I assay in early diagnosis of acute myocardial infarction. N Engl J Med 2009; 361: 868–77. 5 Jaffe AS, Apple FS. High-sensitivity cardiac troponin: hype, help, and reality. Clin Chem 2010; 56: 342–4. 6 Sabatine MS, Morrow DA, de Lemos JA, Jarolim P, Braunwald E. Detection of acute changes in circulating troponin in the setting of transient stress test-induced myocardial ischaemia using an ultrasensitive assay: results from TIMI 35. Eur Heart J 2009; 30: 162–9. 7 Mingels AMA, Jacobs LHJ, Kleijnen VW, Laufer EM, Winkens B, Hofstra L et al. Cardiac troponin T elevations, using highly sensitive assay, in recreational running depend on running distance. Clin Res Cardiol 2010; 99: 385–91.

PTH-095 Surreptitious use of non-steroidal anti-inflammatory drugs and aspirin may be responsible for small bowel injury seen by capsule endoscopy

Introduction Non-steroidal anti-inflammatory drugs (NSAIDs) and aspirin can cause small bowel injury and present with anaemia, bleeding or symptoms suggestive of Crohns disease, the most common indications for capsule endoscopy (CE). Previous studies have suggested that the surreptitious use of these drugs may be a common cause of unexplained peptic ulcer disease.1 We hypothesised that surreptitious NSAID or aspirin use occurred in patients undergoing CE and that this might be responsible for symptoms or abnormalities being investigated. Methods Demographic data, indications for CE and medications were recorded prospectively. A salicylate spot test and gas chromatography mass spectrometry for NSAID metabolites were performed on urine samples of consecutive patients undergoing routine CE. Videos were analysed by an experienced gastroenterologist who was blinded to the urinalysis results. Results Seventy-six patients (52 female; mean age 50 years) underwent CE for suspected small bowel pathology. Urinalysis was positive in 13.6% of patients (n=10/76), although only one of these patients declared the relevant drug (aspirin) in their drug history. The indication for CE in the 10 patients included iron deficiency anaemia (n=2), investigation of suspected active Crohns disease (n=7) and possible coeliac complications (n=1). The presence of salicylates was detected in 3.9% of patients (n=3) while NSAID metabolites were detected in 9.2% (n=7: 6 patients ibuprofen alone and both ibuprofen and diclofenac in 1 patient). While CE was normal in 2 patients, positive findings were seen in 80% of patients (n=8) which included the presence of erosions± red patches in 5 patients, small bowel ulceration in 2 patients and ulceration with early stricturing in one patient. Follow-up data revealed that the patient with small bowel stricturing was subsequently diagnosed as Crohns disease while a patient with small bowel ulceration underwent small bowel resection at a further presentation which confirmed NSAID enteropathy histologically. Conclusion 13.6% of patients undergoing capsule endoscopy were taking NSAIDs or aspirin, of which the majority were not declared in the clinical history. In 11.8% of patients, NSAIDs or aspirin could have been contributing to the symptoms or anaemia being investigated. Patients should be carefully questioned about their use of these drugs and over the counter medications which might contain them, prior to CE.

Outcomes following gastrostomy: radiologically-inserted v. percutaneous endoscopic gastrostomy

Gastrostomy insertion has been demonstrated to be of benefit in selected patients. Percutaneous endoscopic gastrostomy (PEG) using the pull-through technique is the most widely used insertion method, but it is recognised to have important complications, particularly in patients with respiratory risk factors. An alternative is a radiologically-inserted gastrostomy (RIG). It has been suggested that RIG may be advantageous in patients who are potentially at ‘high risk’ from respiratory complications. However, there are no large studies comparing PEG v. RIG. All patients referred for a gastrostomy are prospectively included in a database along with demographic, biochemical and outcome data. Analysis of gastrostomy insertions over the period February 2004–February 2007 was performed with reference to method of insertion and outcome at 30 d. Selection for method of insertion is left to the discretion of the referring clinician. Patients were allocated to the following subgroups: cognitive impairment (n 5); dysphagic stroke (n 36); nasopharygeal cancer (n 175); neurological (n 116); other (n 71). Over the study period 170 RIG and 233 PEG were inserted (mean age 62 years, 268 males). There were no differences in age between the RIG group and PEG group and case mix was comparable except in the nasopharyngeal cancer group (proportionally more RIG). The RIG 30 d mortality was twenty-six of 170 (15.3%) and the PEG 30 d mortality was twenty-five of 233 (10.7%; P= 0.17). Mortality at 1 year was ninety-two of 170 (54.1%) for RIG and 131 of 233 (56.7%) for PEG (P= 0.60). Within subgroups the only significant difference in 30 d mortality was in those patients with nasopharyngeal cancer: fourteen of 106 (13.2%) for RIG and one of 69 (1.4%) for PEG (P = 0.005). However, patients referred for RIG were significantly older than those referred for PEG (mean age (years) 59.7 v. 64; P= 0.019) and had a higher prevalence of significant comorbidities (21.1% in the PEG group and 37.7% in the RIG group). Overall, RIG and PEG appear to have similar 30 d mortality rates. In patients with nasopharyngeal cancer there was a higher mortality in those referred for RIG; however, pre-selection by the referring clinician as a result of perceived risk of endoscopic insertion may have biased the outcome. A randomized trial comparing both methods in this subgroup is needed.

* Is there a role for faecal elastase-1 in patients referred to a luminal gastroenterology service?

Introduction Pancreatic disease can be subtle particularly in the early stages and therefore may be missed. Symptoms of pancreatic disease are not specific and therefore patients may present to gastrointestinal (GI) services but be incorrectly diagnosed with an alternative disorder. The authors analysed a large cohort of patients referred to our unit for investigation of GI symptoms to try to identify predictors of pancreatic disease and the utility of faecal elastase-1 (Fel-1) as a marker of pancreatic disease. Methods A database of patients referred to our unit between January 2005 to June 2009 for investigation of GI symptoms was examined. This database included demographics, reason for referral, bowel frequency, Fel-1 level, abdominal imaging findings and final diagnosis. Fel-1 was considered abnormal below 200 μg/g stool. Using this cut off univariate analysis was performed to identify potential predictors of pancreatic disease. Variables with a p value <0.1 were entered into a logistic regression. Results 621 patients (mean age 48.1, 224 males) were analysed. The majority had been referred for abdominal pain (n=125), diarrhoea (n=426) or weight loss (n=46). The prevalence of abnormal Fel-1 was 55/621 (8.9%, 6.7–11.4). The prevalence of a low faecal elastase-1 in patients with abdominal pain was 7/125 (5.6%), diarrhoea 36/426 (8.5%) and weight loss 4/46 (13.0%). The prevalence of abnormal pancreatic imaging was 12/55 (21.8%, 11.8–35.0). Univariate analysis showed Fel-1<200 to be associated with male gender (OR 1.4), age >50 (OR 2.4) and diabetes (OR 4.6). On multivariate analysis only age and diabetes were independent risk factors. The sensitivity, specificity, positive predictive value and negative predictive value for Fel-1<200 was 100%, 92.9%, 21% and 100% respectively. Receiver operating characteristic curve analysis showed that Fel-1<200 had an area under the curve of 0.97 (0.95–0.99, p=0.008). Conclusion Exocrine pancreatic disease is a common problem in patients referred to GI services and is associated with increasing age and the presence of diabetes. Fel-1 accurately identifies those patients with underlying pancreatic disease. The authors would suggest that Fel-1 should be performed routinely in patients presenting to a general luminal gastroenterology service with symptoms of abdominal pain, diarrhoea and particularly weight loss.

Outcomes Following Gastrostomy: Radiologically Inserted Vs. Percutaneous Endoscopic Gastrostomy

Gastrostomy insertion has been demonstrated to be of benefit in selected patients. Percutaneous endoscopic gastrostomy (PEG) using the pull-through technique is the most widely used insertion method, but it is recognised to have important complications, particularly in patients with respiratory risk factors. An alternative is a radiologically-inserted gastrostomy (RIG). It has been suggested that RIG may be advantageous in patients who are potentially at ‘high risk’ from respiratory complications. However, there are no large studies comparing PEG v. RIG. All patients referred for a gastrostomy are prospectively included in a database along with demographic, biochemical and outcome data. Analysis of gastrostomy insertions over the period February 2004–February 2007 was performed with reference to method of insertion and outcome at 30 d. Selection for method of insertion is left to the discretion of the referring clinician. Patients were allocated to the following subgroups: cognitive impairment (n 5); dysphagic stroke (n 36); nasopharygeal cancer (n 175); neurological (n 116); other (n 71). Over the study period 170 RIG and 233 PEG were inserted (mean age 62 years, 268 males). There were no differences in age between the RIG group and PEG group and case mix was comparable except in the nasopharyngeal cancer group (proportionally more RIG). The RIG 30 d mortality was twenty-six of 170 (15.3%) and the PEG 30 d mortality was twenty-five of 233 (10.7%; P= 0.17). Mortality at 1 year was ninety-two of 170 (54.1%) for RIG and 131 of 233 (56.7%) for PEG (P= 0.60). Within subgroups the only significant difference in 30 d mortality was in those patients with nasopharyngeal cancer: fourteen of 106 (13.2%) for RIG and one of 69 (1.4%) for PEG (P = 0.005). However, patients referred for RIG were significantly older than those referred for PEG (mean age (years) 59.7 v. 64; P= 0.019) and had a higher prevalence of significant comorbidities (21.1% in the PEG group and 37.7% in the RIG group). Overall, RIG and PEG appear to have similar 30 d mortality rates. In patients with nasopharyngeal cancer there was a higher mortality in those referred for RIG; however, pre-selection by the referring clinician as a result of perceived risk of endoscopic insertion may have biased the outcome. A randomized trial comparing both methods in this subgroup is needed.